Economist Challenges Governor Kitzhaber to Make Evidence-Based Practice the Standard of Care

Right now insurers such as Regence BlueCross BlueShield are spending millions of dollars, he says, on medical services not backed by scientific evidence

OPINION – May 8, 2012 -- Regence's recently announced decision to drop contracts with certain provider networks used by individual policyholders in the Portland area is an ominous and dangerous development. Not only does it challenge the single thing most healthcare consumers think is best about the current payment system -- wide choice and dependable coverage of one's personal caregivers- it is inexplicable as a first line of response to the problem of costs.

A far more auspicious tool would involve fundamental provider reimbursement reform. Key among the components of such a package should be the use of "evidence-based practice" as the default standard of care for purposes of payment. Right now, Regence and other insurance carriers throw hundreds of millions of dollars at medical services that are not backed by hard scientific evidence even where evidence-based practices are available and could reduce costs and increase quality.

Although evidence-based practice has been well recognized in the medical field for years, it is still severely under-used, especially in the private insurance sector. To gain real traction, it needs a champion in the right place and maybe also a triggering event like a threat to access and to the continuity of the
doctor-patient relationship. Governor Kitzhaber should come forward as that champion. His professional background and commitment to evidence-based practice is unquestioned.

The Governor's first effort should be to task the State Insurance Division
to make evidence-based practice the standard of care for reimbursement in the private insurance market. The Division now has the funding and actuarial capacity to take on this kind of job, courtesy of federal grants under the Affordable Care Act. Evidence- based practice is where the savings and quality improvement opportunities can be found. Why threaten access and disrupt practice relationships before fully exploring potentially more productive avenues?

Larry Kirsch is a health economist and managing partner of IMR Health
Economics. He has served as an expert witness in health insurance rate
review cases throughout the country.

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I agree with much of the premise in this article, and believe that we should only pay for treatments that have a recognized therapeutic value. There should be cost benefit as well facored in, and comparative effectiveness should be part of the formula. I can guarantee this would be applauded by payers, it is the PHYSICANS that have been reluctant to commit to this practice. EHRs have the ability to hard-wire in best practices, and evidence based medicine. The response from physicians has, to a large extent, been "This is cook book medicine". There generally is not only ONE care path supported by the evidence, and that is where EBM tends to fall apart. However, we can insist on lower cost care with the same outcomes. I dont know about the rest of you, but I like my MD to follow a proven course, not just what he/she was taught 20 years ago. Payers generally apply Evidence Based Medicine to medical necessity criteria. The biggest barrier is the physician who feels his autonomy is challenged. An MRI for every headache is NOT EBM. And lets look at the evidence around back surgeries, etc. The list is endless. Tony Finleyson

Mr Kirsch is absolutely correct.Nurses have witnessed the waste in our health care system for years. Years ago insurance companies refused to pay for classes that taught people with diabetes how to manage their illness while at the same time paying over $5,000 per visit on average for emergency department treatment when their blood sugar went too high or too low. The cost of the class for a full three months at that time was $350. This is an old issue related to the glamour of high cost treatment and facilities that resemble hotels and ski lodges rather than places for patients to be treated well so they can leave. An related to the compensation for medical specialists. Susan King

Maybe insurers don't stand up against ineffective treatment because they get tarred and feathered by the public when they do. See "HDC-ABMT" for how that story plays out. We've trained people to be deeply skeptical of payers (including public payers, see the discourse around IPAB) and deeply trusting of providers. With those biases why would anyone see medical effectiveness as anything other than rationing? BJ Cefola

"Evidence-based medicine" sounds all well and good. However, what passes for evidence with prescription drugs is often cherry-picked data from original clinical trials. While the raw data remains hidden, hiding behind the smoke and mirrors of being "proprietary", the "good bits" from the trials are trumpeted and heavily marketed to doctors (think ghost-written articles, trips to the Bahamas, "thought leaders" in academic medicine proclaiming the worth of the drug while being on the pharma payroll for touting it, drug reps telling half-truths, and so forth). Thus, the doctor is placed in the position of having to believe whatever evidence he is given (often the opposite of what he/she might see happening to the patient on the drug before his/her very eyes)... Unless and until the raw data from clinical trials, warts and all, is demanded by entities such as state Medicaid formularies and private health insurers, the game will go on and hundreds of thousands of people will be on drugs unnecessarily, and often to their harm. Approximately 100,000 people every year die in the U.S. of negative pharmaceutical drug side effects. Ellen Liversidge